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Background: In India, less than 5% of women get routine screening for breast cancer due to lack of awareness and the absence of a coordinated national breast cancer screening programme. A community health initiative was launched by Niramai in collaboration with City Health officials in Bangalore as a pilot to increase awareness and make breast health screening available to all. Free breast cancer screening using AI powered Thermalytix test is being offered to all the underprivileged women walking into Bruhat Bengaluru Mahanagara Palike (BBMP) government hospitals from November 14, 2017 till today (after a break for 15 months during COVID). Material(s) and Method(s): This observational study was conducted in 22 BBMP-affiliated primary health centers where outpatient women over the age of 18 years and not pregnant were enrolled. The procedure included a briefing on camp procedures, taking patient consent, identification of eligible candidates, general health education, and conducting the Thermalytix test by a healthcare worker who was trained to use the Thermalytix software tool. Women were triaged using the output generated by Thermalytix 180. Those triaged as red were referred for further detailed imaging investigation in a district hospital using mammography, ultrasound and FNAC/biopsy. Result(s): A total of 6935 women underwent Thermalytix screening in 22 BBMP hospitals during Nov 2017 to July 2022. A total of 1687 participants were excluded from the analysis as they did not meet the eligibility criteria. The median age of the 5248 eligible participants was 42 years (range 18-86). Among them, 90 women (1.71%) had previously noticed a lump in their breast, 431 women (8.12%) had breast pain, 16 women had complained of nipple discharge, and 5 women had noticed skin discoloration. When screened, 62 (1.2%) women were detected with abnormalities and triaged positive by Thermalytix. Among them 11 women have so far gone through diagnostic investigations, of which 8 were radiologically positive and were recommended for histopathology correlation. The overall test positivity rate of Thermalytix in this cohort was 1.2% and positive predictive value with radiological positivity as reference was found to be 9/11 = 81.81%. Furhter histological analysis reported 1 DCIS and 8 benign fibroadenoma. The tests were conducted in screening camps and the average cost of conducting the test in the field came to around 6.5 USD per person. Conclusion(s): Thermalytix could be a potential automated screening tool for population-level screening in resource constrained settings. The portable equipment enabled easy movement across different PHCs. Since it is a privacy-aware test, there was less refusal to participate in the test. Community mobilization with the help of the local government health officials was crucial to ensure walk-ins. Conflict of interest: Ownership: yes Board of Directors: yes Corporate-sponsored Research: yesCopyright © 2022 Elsevier Ltd. All rights reserved
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Introduction. The SARS-CoV-2 infection rate and the COVID-19 death rate were relatively high in the Netherlands during the first wave of the COVID-19 pandemic (2.7 and 7.2 times higher than in Norway, respectively). Moreover, social measures differed between the two countries. This study aimed to compare the effect of the pandemic on breast cancer incidence and stage between the Netherlands and Norway. Methods. Women diagnosed with DCIS or invasive breast cancer between January 2017 and December 2021 were selected from the Netherlands Cancer Registry and from the Cancer Registry of Norway. The COVID-19 period was divided in three approximately equal periods: March-September 2020 (first wave), October 2020-April 2021 (second wave), May-December 2021 (post-second wave). Breast cancer incidence during the COVID-19 periods was compared with averaged data of the corresponding reference period: March-September 2017, 2018, 2019 (first wave-ref), October-April 2017, 2018, 2019 (second wave-ref), May-December 2017, 2018, 2019 (post-second wave-ref). Incidences were compared by age group, clinical tumor stage, and method of detection. Results. The number of breast cancer diagnosis and the breast cancer incidence are shown in Table 1. Compared to the reference period, breast cancer incidence was lower during the first wave in the Netherlands and Norway (IRR: 0.72;95%CI: 0.70-0.75;IRR: 0.83, 95%CI 0.78-0.88, respectively), and was higher post-second wave in Norway (IRR: 1.10, 95%CI: 1.04-1.16) (Table 1). During the first wave, breast cancer incidence was lower in all age groups in the Netherlands (age < 50 IRR: 0.85, 95%CI: 0.79-0.91;50-69 IRR: 0.64, 95%CIL 0.61-0.67;70-74 IRR: 0.61, 95%CI: 0.56-0.67;>74 IRR: 0.86, 95%CI: 0.80-0.93, respectively). During the first wave, incidence was lower in women aged 50- 69 in Norway (i.e., women eligible for screening;IRR: 0.68, 95%CI: 0.62-0.74). Post-second wave incidence was higher in women aged 50-69 and >74 in Norway (IRR: 1.09, 95%CI: 1.01-1.17;IRR: 1.13, 95%CI: 1.00-1.28, respectively). In the first wave the incidence of DCIS, stage I tumors, and screen-detected tumors was lower in the Netherlands (IRR: 0.55, 95%CI: 0.50-0.61;IRR: 0.62, 95%CI: 0.59-0.65, IRR: 0.36, 95%CI: 0.33-0.38, respectively) as well as Norway (IRR: 0.66, 95%CI: 0.54-0.79;IRR: 0.73, 95%CI: 0.66-0.81, IRR: 0.46;95%CI: 0.40-0.52, respectively). Conclusion. The current study showed that the incidence of early-stage tumors mainly decreased. Moreover, during the first wave of the pandemic breast cancer incidence decreased in all age groups in the Netherlands but only in women aged 50-69 in Norway. The relatively high infection and death rate in the Netherlands might have increased the fear of patients to visit the general practitioner (GP) and/or to overburden the healthcare system at the start-up of the pandemic. In addition, it might have reduced the capacity at the GP. As a result, appointments with the GP might have been postponed, resulting in a decrease in the number of breast cancer diagnoses in all age groups. A catch-up in breast cancer diagnoses was seen post-second wave in Norway, but not in the Netherlands. Incidence rates should therefore be monitored in the coming period. (Table Presented).
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Sinonasal cancer accounts for roughly only 3% of upper respiratory tract malignancies and generally presents as a primary malignancy. Although extremely rare, the sinonasal cavity is also a known location for metastasis, with 8% of these cases originating from primary breast cancer. When attempting to differentiate primary disease from metastasis, immunohistochemical analyses play a crucial role in reaching the correct diagnosis. To date, there are a handful of reports describing metastasis involving the paranasal sinuses but even fewer reporting primary sinonasal cancer with coexisting primary malignancy. Here we present a case of primary sinonasal adenocarcinoma in the setting of a long-standing history of breast cancer. The patient, a 73-year-old female, was diagnosed with T1cN1aM0, progesterone receptor positive and estrogen receptor negative ductal carcinoma in situ of the left breast in November 2019. She subsequently underwent bilateral mastectomy and treated with 3 cycles of chemotherapy and anastrozole, which were both discontinued due to intolerance. Of note, in March 2019, MRI of the head incidentally found a 3 x 2 cm mass in right nasal cavity extending into ethmoid sinus. One year later, she presented with mild right sided nasal obstruction and drainage, and biopsy revealed squamous and respiratory mucosa with chronic inflammation. The patient elected to cancel initial surgical resection of the mass due to the COVID-19 pandemic. The patient returned in March 2022 with complaints of eye pressure, double vision, headaches, and worsening nasal obstruction. PET/CT scan was negative for distant metastasis but demonstrated increased uptake in sinus cavity. MRI showed a larger 5 x 3.7 cm mass impressing on medial inferior margins of orbit. Imaging also suggested evidence of dehiscence of lamina and irregular neo-osteogenesis of the skull base. She underwent approach and resection of the mass with histology demonstrating a well differentiated, low grade non-intestinal mucinous adenocarcinoma. Immunohistochemistry was positive for pankeratin and CK7, favoring a primary sinonasal origin. It was estrogen receptor negative and negative for GATA3, a sensitive and fairly specific stain in mammary carcinoma. Adjuvant radiation was recommended postoperatively, however the patient declined this therapy. This case highlights the role of immunohistochemistry to discriminate a new primary cancer from metastasis in patients with a history of breast cancer. Clinically, patients with sinonasal metastasis can present with symptoms ranging from unilateral nasal obstruction, facial pain, diplopia, and decreased vision. On imaging, suspicion of malignancy is raised when there is evidence of destruction of bony boundaries and invasion of surrounding tissues such as the orbit and anterior skull base, as found in our patient. Notably, metastasis to the paranasal sinuses can mimic a primary cancer of the nasal cavity, with both tumors showing epithelial differentiation. However, primary tumors often show neoplastic changes in the overlying respiratory epithelium and do not express estrogen receptor, progesterone receptor, or HER2 positivity, which are known to be correlated with breast cancer. In this setting, GATA3 and estrogen receptor negativity allowed us to diagnose primary nasal cancer more confidently. Therefore, clinicians should be aware of metastatic disease and expand immunohistochemistry panels when appropriate.
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Aims: COVID-19 has had much publicised impacts on cancer diagnosis within Victoria. Statewide there are thought to be over 2000 undiagnosed malignancies since the start of the pandemic, particularly in men andwithin melanoma, prostate cancer and head and neck malignancies. Regional and local patterns of presentation may differ from statewide data and local data suggesting under diagnosis may assist in regional service planning. Method(s): Prior statistical analysis using Victorian Cancer Registry (VCR) data has been used to identify a shortfall in cancer diagnoses. VCR notifications for 2019-2021 inclusive for the Barwon southwest region were utilised for this review. Notifications for the five most common cancers were assessed for major variations in notifications, taking a pragmatic approach to classify a major variation where notifications changed by more than 10% from 2019 levels in either or both of 2020/2021. Result(s): Total notifications did not change significantly from 2019- 21 (3676, 3777, 3731, respectively). Likewise, there were no obvious reductions in notification by sex or in older patients. While breast cancer notifications dropped in 2021 but rebounded in 2022 (424, 348, 453), diagnoses of DCIS increased each year (36, 55, 68). Lung cancer notifications dropped in 2021-22 (336, 249, 269) as did notifications of colorectal cancer (452, 418, 361), while prostate cancer notifications rose (531, 662, 654) and melanoma notifications were fairly consistent (145, 158, 141). Conclusion(s): Using a pragmatic approach to identifying major variations in cancer notifications during the COVID-19 pandemic, regional data suggests a reduction in lung cancer and colorectal cancer diagnoses in our region. Unlike reported statewide data, there was not an obvious drop in notifications of prostate cancer or melanoma. Further analysis of this data may help better identify cohorts with under diagnosis in our region.
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Background: Nutrition and lifestyle interventions are instrumental in modifying cancer risk. These changes are often challenging for patients to make due to residual side effects from active treatment and/or ongoing toxicities from current treatment. The SHINE (Survivorship and Health Interventions in Nutrition and Exercise) Program is a wellness program for patients with breast cancer focusing on three pillars of nutrition, exercise and community in order to improve overall health outcomes and decrease the risk of cancer recurrence. Methods: Participants in SHINE have either been diagnosed with ductal carcinoma in situ (DCIS) and/or stage I-IV breast cancer. They are referred to the program at the threemonth breast surgery post-operative follow-up appointment or any time after that. All patients are referred to meet with a registered dietitian (RD) and integrative health coach, who provides counseling and education on how to reduce risk through diet and lifestyle, using evidence-based recommendations. Patients are provided with support and accountability. A collaborative program, the Physician Referred Exercise Program (PREP), was established with our health system's medical fitness center, Valley Health LifeStyles. Patients undergo a fitness assessment that focuses on aerobic fitness, muscle strength and endurance, flexibility, & functional activity. Each patient then receives an exercise prescription developed by a degreed exercise specialist, taking into account both the physician's & patient's recommendations & goals. Results: Each component of the SHINE Program has been developed in various stages due to the COVID-19 pandemic. 336 patients with either DCIS or stage I-IV breast cancer have been seen by the RD from December 2020 through January 2022. Mean number of visits/ patient: 1.89 (range 1-8). N = 48 were participants in a 12-week study on the feasibility of nutrition counseling and impact on quality of life (QOL) which is still in progress. 76 patient referrals have been placed to the PREP program from August 2021-February 2022. Multiple community programs (Table) have been created for patients to help them develop shared experiences & camaraderie with each other so that they can better integrate new ideas and lifestyle modifications. Conclusions: The SHINE Program addresses care for the whole person, empowering individuals to live their healthiest lifestyle. Future work will focus on clinical trials to evaluate the benefits of these individual and collective interventions on overall QOL, QOL subscales (physical, psychological, social & spiritual well-being), & survivorship symptoms.
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Background: Disparities in cancer screening have been well documented during the Covid-19 pandemic. However, there are limited patient-reported data describing the prevalence and drivers of patient hesitancy towards cancer screening and willingness to resume screening. As health systems continue to experience pandemic-related capacity strain, there is an urgent need for innovative models of re-engaging patients in preventive screening. To address this issue, we developed a medical student-led, high-touch outreach model to re-engage primary care patients at Brookside Community Health Center in cancer screening. Methods: We iteratively optimized semi-structured call scripts and surveys in English and Spanish to contact patients overdue for mammography screening. Student callers included medical and pre-medical students with native Spanish fluency. Using the call script, students identified patient-reported barriers and facilitated mammogram scheduling for consenting patients. For consenting patients, student callers placed a telephone encounter with a pended screening mammogram order in the electronic medical record. PCP confirmation of the order triggered outreach by the radiology department for mammogram scheduling. Patients also received reminder calls from students the week of their appointment. Primary outcomes include screening consent rates, mammogram scheduling and completion rates, and screening results. Patient survey responses were securely recorded using the REDCap survey platform. Results: 198 patients were eligible for the intervention. 60% are primarily Spanish-speaking and 81% are insured by Medicaid. 145 patients (73%) have successfully been contacted, of which 129 (89%) consented for mammogram screening. 74 (57%) of the consenting patients have scheduled their mammogram and 38 (29%) have completed their mammogram. 36% of consenting Spanish-speaking patients with active mammogram orders did not have a mammogram scheduled, compared to 9% of consenting English-speaking. To date, 6 patients had abnormal mammograms requiring subsequent diagnostic imaging, and 1 patient was diagnosed with ductal carcinoma in situ requiring oncologic care. Qualitative analysis of patient surveys found that primary barriers to screening included factors associated with the Covid-19 pandemic (32.9% of contacted patients), lack of awareness of overdue status (25.9%) and patient unavailability (e.g. outside of country) (20%). Conclusions: In this single-center quality improvement study, we found that patients had a high willingness to engage in cancer screening during the pandemic and that trainees can play a vital role in re-engaging patients in preventative care. The disparity between Spanish and English-speaking patients' ability to schedule a mammogram after the consent process suggests that patients with limited English proficiency face additional challenges in accessing screenings.
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Background: Significant challenges exist in recruiting newly diagnosed ductal carcinoma in situ (DCIS) patients to participate in presurgical intervention trials. Perceived motivators and barriers to participation have not been formally studied from the patient or healthcare provider (HCP) perspective. Based on our experience in the Promise Study (NCT02694809), we hypothesized that delaying surgery and concern for side effects are barriers to trial participation and that access to new treatments and financial benefits are motivators. To improve recruitment, we conducted focus groups to better understand barriers and motivators for trial participation in our patient population. Methods: Three focus groups with post-menopausal women (PMW) without history of DCIS, one focus group with patients previously treated for DCIS, and two HCP focus groups were conducted. Due to COVID-19, the focus groups took place online via videoconferencing and included participants from across the United States. A thirdparty facilitator generated discussion on predetermined topics including knowledge of DCIS, clinical trial recruitment materials, hormone replacement therapy, healthcare delivery and clinical trials during COVID-19, and perceived motivators and barriers to trial participation in general and specifically for women with DCIS. Here, we focus on comparing perceived influential factors for patient participation in DCIS clinical trials in PMW and HCP focus groups. Qualitative thematic analysis was completed on focus group transcripts in NVivo. Results: PMW had no knowledge of DCIS prior to the focus groups and believed DCIS should be removed promptly. PMW believed barriers to DCIS clinical trial participation included the potential for the study drug to cause harm, distrust of medicine, and the fact that DCIS is not life-threatening. PMW identified helping future DCIS patients, accessing better treatment, and easing anxiety as motivators for DCIS trial participation. HCPs believed patients were motivated by increased monitoring by the medical team, financial incentive, and access to newer treatment. HCPs believed that delays in DCIS surgery, the potential for the intervention to be harmful or ineffective, and the trial causing patient anxiety were barriers. Neither group emphasized time commitment as a barrier to DCIS trial participation. PMW were not motivated by financial incentives. Conclusions: Knowledge about DCIS is lacking in PMW. PMW and HCPs agreed that the risk of harm caused by study interventions is a deterrent to trial participation and that access to superior treatment is a motivator. However, PMW and HCPs did not agree on other motivators and barriers which could lead to missed recruitment opportunities. Providing educational materials on DCIS and addressing motivators and barriers to clinical trial participation may increase recruitment to presurgical DCIS trials.
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Background: Fatigue is common in patients undergoing radiotherapy (RT). Melatonin, an inexpensive natural supplement, may improve symptoms and attenuate the side effects of RT. The effect of melatonin for prevention of fatigue and other symptoms was evaluated in a double-blind placebo-controlled trial. Methods: Early-stage or ductal carcinoma in-situ breast cancer patients ≥ 18 years, female, Eastern Cooperative Oncology Group performance status (ECOG PS) < 3, hemoglobin ≥9 g/dL. RT with curative intent, randomized 1:1 to melatonin 20 mg or oral placebo, starting night before RT initiation until 2 weeks post-RT. Sample size of 142 evaluable patients in each arm for 80% power and interim analysis at mid recruitment using the unified family method rho = 0.3. Randomization stratified to RT duration (< 3 weeks, ≥3 weeks) and prior chemotherapy. Primary outcome : Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue subscale after completion of RT with additional scores measured at baseline, 2 and 8 weeks post-RT. Secondary outcomes : FACIT-F subscales, Edmonton Symptom Assessment System (ESAS) and Patient Reported Outcomes Measurement Information System (PROMIS) Fatigue-Short Form 8a. Secondary analyses reported using an F-test at a 5% significance level. Results: For this interim analysis, 85 patients screened;80 randomized;39 received melatonin and 38 placebo. 72 included in the analysis as 5 patients had no post baseline FACIT score. Characteristics of age, race, and ECOG PS similar in both arms. Treatment X time for FACIT-Fatigue not significant for melatonin compared to placebo (p .83). FACIT physical, emotional, and functional wellbeing scores not significantly different (p .35, .62, and .71) but showing a trend for social well-being (p .06). PROMIS scores not changed over time (p .34). ESAS individual symptoms of anxiety, well-being, drowsiness, poor appetite, nausea, pain, shortness of breath, sleep and tiredness not significant, except for depression (p.04). However, a decrease of 0.01 unit in depression score is not considered clinically significant. No grade 3 or 4 adverse events. No participants died during study, 2 died after study completion from breast cancer recurrence. 16 withdrew prior to study completion because of adverse events, unrelated hospitalizations, RT discontinuation, and COVID-19 precautions. Trial was stopped based on statistical analysis demonstrating no difference for primary outcome and imminent expiry of available drug. Discontinuation was approved by Data Safety Monitoring Committee. Conclusions: Melatonin did not prevent fatigue in patients with early stage breast cancer undergoing RT. Melatonin also demonstrated no benefit for other symptoms, except depression. Analysis showed little evidence of an effect, and the trial was terminated early.
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STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic has caused marked declines in cancer screenings and exacerbated preexisting disparities in cancer screening among vulnerable patient populations. DESCRIPTION OF PROGRAM/INTERVENTION: Despite the availability of robust quantitative data reporting disparities in cancer screening during the COVID-19 pandemic, there is a dearth of patient-reported data available describing prevalence and drivers of patient hesitancy towards cancer screening and patient willingness to resume cancer screening. Additionally, as health systems continue to experience pandemic-related bandwidth strain, there is an urgent need to develop innovative models of re-engaging patients in preventive screening that can successfully be implemented in the current healthcare environment. To address this issue, we developed a medical student-led, high- touch outreach model to re-engage primary care patients of the Brookside Community Health Center (BCHC) in cancer screening. We iteratively optimized semi-structured call scripts and surveys in English and Spanish to contact patients overdue for mammography screening. Student callers consisted of medical students and premedical students with native Spanish fluency. Call script language allows students to identify patient-reported barriers and facilitates re-scheduling of mammograms for consenting patients. For consenting patients, student callers input a telephone encounter with a pended screening mammogram order in the electronic medical record;the note is then routed to the patient's PCP for signing. Patients additionally receive reminder calls from students the week of their mammography appointment. MEASURES OF SUCCESS: Primary outcomes include screening consent rates, rates of mammogram scheduling and completion, and screening results. Patient response to survey prompts and student call summaries were securely recorded and analyzed utilizing the REDCap survey platform. FINDINGS TO DATE: 198 patients eligible for the intervention have been identified, of which 60% are primarily Spanish-speaking and 81% are enrolled in MassHealth (MA Medicaid). 145 patients (73%) have successfully been contacted, of which 129 (89%) consented for mammogram screening. 74 (57%) of the consenting patients have scheduled their mammogram, and 38 (29%) have completed their mammogram. Of note, 6 patients had abnormal mammograms requiring subsequent diagnostic imaging, and one patient was diagnosed with ductal carcinoma in situ requiring establishment of oncologic care. A preliminary qualitative analysis of patient surveys has found that primary barriers to screening included factors associated with the COVID-19 pandemic, lack of awareness of overdue status, and patient unavailiability (e.g. temporarily out of the country), and miscommunication between patients and the clinic. KEY LESSONS FOR DISSEMINATION: In this single-center quality improvement study, we found willingness to engage in cancer screening during the pandemic remains high and trainees can play a vital role in mitigating screening disparities during the pandemic.
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Radiotherapy is an essential treatment in the local control of breast cancer. Standard treatment is currently carried out in 15 daily sessions. At present, following the results of the phase III Fast-Foward trial and in view of the situation triggered by COVID-19, the number of sessions has been reduced to 5. We present the data of our series to evaluate the results of the extreme hypofractionation scheme as a radiotherapy treatment for breast cancer at the Multihospital Clinical Unit of Radiation Oncology of Aragón (UCMORA). Materials and Methods After implantation, 115 patients were treated with 3D conformal radiotherapy between April 2020 and May 2021 at UCMORA using the extreme hypofractionation scheme (26 Gy at 5.2 Gy per fraction in 5 fractions). Demographic, tumor, dosimetric and toxicity characteristics were analyzed. Results The mean age was 63.5 years. 53 patients were treated at the Lozano Blesa Clinical Universitary Hospital and 62 at the Miguel Servet Universitary Hospital, in total 59 right and 56 left breasts. The predominant histology was infiltrating ductal carcinoma (84.3%), followed by infiltrating lobular carcinoma (10.4%), ductal carcinoma in situ (4.3%) and mucinous (0.9%). 51.7% were luminal A, 39.1% luminal B, 1.8% Her2 positive and 7.8% triple negative. In relation to staging, we found 4pTis, 8pT1a, 45pT1b, 58pT1c, 2Nx, 8N0, 1Nmi and 13N1a. Only 45% had acute toxicity at one month after the end of treatment, predominantly G1 radiodermatitis (86.6%), followed by G2 (11.2%) and G3 (2.2%). When analyzing the dose-volume histograms, values were obtained for ipsilateral lung V8 between 1.32 and 21.2%, for the heart, in case of left breast a median for V1.5 of 8.2% and 1.05% for V7;in case of right breast the median Dmed for the heart was 0.5Gy (Figure Presented) Conclusion Ultra-hypofractionated whole breast radiotherapy as a radiation treatment for breast cancer is well tolerated, reduces costs and number of sessions, while increasing comfort for patients.
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INTRODUCTION: The COVID-19 pandemic peaked in New York City in Spring 2020. From March 20-May 4, all elective operations were suspended due to the number of hospitalized Covid-19 patients. In this study, we sought to describe patterns of care for surgical patients during this time. METHODS: An IRB approved retrospective review was performed of patients who presented to our hospital system from March-May 2020, diagnosed with breast cancer or atypia. RESULTS: We identified 75 patients with breast cancer and 19 patients with atypia. According to standard of care, 55/75 (73%) cancer patients would have undergone upfront surgery. 2/55 (4%) instead were treated with neoadjuvant chemotherapy (NCT), 34/55 (62%) with neoadjuvant endocrine therapy (NET), and 19/55 (34%) had no immediate treatment. 12/19 (63%) with no immediate treatment had DCIS only. 7 had invasive disease, and mean days from diagnosis to surgery was 63 days (range 47-79). One patient had a positive node. A total of 20/75 (27%) patients needed NCT based on advanced stage or molecular profile and had no delay in starting treatment. Of the 34 NET patients, 5 (14.7%) were treated for approximately 6 months and 24 (70.6%) were treated for approximately 6 weeks as a bridge to surgery only. Of the 34 patients who received NET, 5 (14.7%) had an apparent decrease in T stage: 3 patients with clinical T1 disease had no residual disease. 2 had clinical T2 and ultimately had pathological T1 disease. Of the 19 patients with atypia, 6 (31.6%) started chemoprevention preoperatively and 1 patient was already receiving it for a previous LCIS diagnosis. All underwent subsequent surgery and 1/19 (5.3%) patients was upstaged to DCIS. CONCLUSIONS: During the peak of Covid-19, with delay of surgery, we observed an increased utilization of NET when compared to usual treatment patterns, with no apparent adverse effects. While further studies are needed to validate our results, we may see more wide spread use of NET in the future to temporize patients as needed.
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Introduction: The burden of the COVID-19 pandemic forced the Dutch health care services to discontinue their national screening programs on 16 March 2020 (week 12). For breast cancer, the program invites women aged 50-74 years for biennial screening mammography. From mid-June 2020 (week 25) the breast cancer screening program was resumed, albeit with reduced capacity (max 60%). We aimed to investigate the impact of resuming the screening program on incidence, tumor-, and T-stage of screen- and non-screen-detected ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC) in the Netherlands. Methods: Women, 50-74 years of age, diagnosed with DCIS or IBC in weeks 2-35 of 2018, 2019 and 2020 were selected from the Netherlands Cancer Registry. Weekly incidence of screen- and non-screen-detected tumors was calculated and expressed per 1 million women aged 50-74 years living in the Netherlands. Weeks 2-35 were divided in seven periods, representing separate phases of the pandemic. For each period, incidence of screen- and non-screen-detected tumors was stratified by clinical tumor stage (TNM) and clinical T-stage. Incidence in each period of 2020 was compared with the incidence in the same period of 2018/2019 (averaged). Results: In weeks 2-35, 7,250 patients were diagnosed in 2018, 7,299 in 2019, and 5,300 in 2020. During weeks 2-12 2020 the weekly average incidence of screen-detected tumors was 42/1 million women aged 50-74. In week 13 incidence dropped to 19, and was almost zero during weeks 14-25. Incidence increased to 4 in week 26, when the screening was gradually restarted, and increased to an weekly average of 24 tumors/1 million in weeks 30-35, when screening had restarted in most of the Netherlands. During weeks 14-16, 17-25, 26-29, and 30-35 2020 incidence of screen detected DCIS, stage I-II tumors and T0-2 tumors was lower than in the same period of 2018/2019. Distribution of tumor- and T-stage in newly diagnosed tumors did not differ between the periods (24% DCIS, 57% stage I, 18% stage II, 1% stage III, 1% stage IV;24% T0, 59% T1, 15% T2, 2% T3, 0% T4). During weeks 2-11 2020 the weekly average incidence of non-screen-detected tumors was 38/1 million women aged 50-74. Incidence dropped to 16 in week 14, and increased to an average of 37 tumors per week in weeks 17-35. During weeks 17-25, 26-29, and 30-35 the incidence and distribution of non-screen-detected DCIS, stage I-IV and T0-4 tumors was comparable with 2018/2019 (weekly incidence (distribution): 3 DCIS (9%), 15 stage I (40%), 13 stage II (36%), 3 stage III (7%), 3 stage IV (8%);3 T0 (9%), 17 T1 (45%), 12 T2 (34%), 3 T3 (8%), 2 T4 (5%)). Conclusion: The temporary suspension of the breast cancer screening program reduced the incidence of breast cancer. After resuming screening the incidence did not raise above the incidence in 2018/2019, therefore it is expected that the incidence will rise during the next months. The results to date did not show a shift towards a higher tumor stage or T-stage.
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Background: Coronavirus disease 2019 (COVID-19) resulted in a global pandemic, which led to deferral of surgeries for early stage breast cancer during March-June 2020. Institutional guidelines were developed to use neoadjuvant endocrine therapy (NET) as a bridge to surgery. As a follow up to initial data presented at SABCS 2020 demonstrating patient acceptance of NET, the present study provides results from a survey which explored psychosocial factors associated with medication compliance. Objective: Primary objective was to identify any barriers to compliance with NET. Method: This was a single institution, prospective study that surveyed patients diagnosed with DCIS and early stage breast cancer at Perlmutter Cancer Center at NYU Langone Hospital and NYU Langone Hospital-Long Island from March 15, 2020-June 1, 2020. Questions were based on the Beliefs about Medicines Questionnaire specific for endocrine therapy (BMQ-AET) and the Medication Adherence Report Scale. Responses were recorded on a Likert scale and included 7 questions regarding perceptions about breast cancer treatment, 10 questions addressing experience with NET, and 5 questions gauging at adherence to NET. Inclusion criteria were males and females older than 18 years old, with an initial diagnosis of DCIS or early stage HR+ Her2/neu-breast cancer, who were prescribed NET. Descriptive statistics were calculated and subgroups were compared using Fisher's exact tests. Analyses were performed using SAS version 9.4. Results: From March 15-June 1, 2020, 13 patients were diagnosed with DCIS and 29 patients with HR+ Her2/neu-breast cancer for whom NET was recommended. Demographics are shown in Table 1. All 42 patients were female with an average age of 60.9 years. Majority of patients were post-menopause (74%) and predominantly white (64%), with an income of less than $60, 000 (52.4%). Average NET duration was 6.7 weeks. Survey responses displayed in Table 2 indicate statistically significant p values in bold. Patients >50 years old, post-menopause and invasive breast cancer had a stronger belief that NET would be helpful, resulting in greater perception to breast cancer treatment and higher adherence to NET. Patients treated with NET for greater than 4 weeks also felt that NET would make them feel well compared to ≤4 weeks. Interestingly, no significant differences in responses based on education or income level were observed. Conclusion: COVID-19 pandemic presented a unique opportunity to use NET, which is often underutilized outside of clinical trials. In this single institution prospective study, we found that post-menopause patients greater than 50 years old with invasive breast cancer perceived hormonal therapy as beneficial to their health, resulting in increased medication compliance. These findings can be used when counseling patients currently treated with NET as well as those patients may be appropriate for NET in the post-COVID era.
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A recently published study from the National COVID Cohort Collaborative (N3C) revealed that COVID-19 (CoV) positive status in cancer patients (pts) was associated with an increased risk of all-cause mortality at 1 year when compared to CoV negative status. In addition, age ≥65 years, Southern or Western US residence, an adjusted Charlson Comorbidity Index score ≥4, multi-tumor sites, and recent cytotoxic therapy were associated with increased risk of all-cause mortality. The CoV pandemic significantly impacted our hospital's operations in 03/2020. Regardless, the hospital remained operational for cancer pts through the entire pandemic. The objective of this study is to investigate the impact of CoV pandemic on breast cancer (BC) treatment and outcomes in our academic medical center in East Tennessee. A retrospective cohort group was identified from a prospectively monitored Cancer Registry database of 706 pts comparing those diagnosed with BC from 3/1/2019-12/31/2019 (G1=406 pts) to those diagnosed from 3/1/2020-12/31/2020 (G2=300 pts). The impact of CoV pandemic was studied utilizing SPSS statistical software. During the pandemic, 26% fewer pts were treated for BC in our hospital, likely resulting from decreased screening rates. Pts in G2 were significantly younger than in G1 (mean age 61.4 vs 63.5), but no difference was observed in racial and insurance status or diagnosis with invasive BC vs DCIS (Table 1). CoV test results for 20 pts from G1 and all 300 pts in G2 (Table 2) were analyzed. Only 8 pts (2.6%) tested positive for CoV (all in G2). For 5 of these 8 pts, CoV positivity had no impact on their care or survival, since CoV infection happened either before or after their BC diagnosis and therapy. CoV caused delay of the first course of treatment in 9/300 (3%) G2 pts: 3/9 delays were due to CoV infection and 6/9 delays were due to implementation of nation-wide CoV pandemic guidelines for care of BC pts. Of the 6/9 pts who experienced delayed treatment, 5 were diagnosed with BC in 03/2020 and 1 in 06/2020, all in the time period of the national "lock-down". Delayed surgical treatment had no impact on patient outcomes. During the pandemic, the number of days from diagnosis to chemotherapy or hormonal treatment was significantly shorter (p<0.05) in the G2 cohort than in the pre-pandemic G1 cohort. The number of days to surgery or radiation treatment although non-significant was also lower in the G2 cohort. CoV did not impact readmission to our hospital within 30 days of surgery. None of the BC pts died from CoV. One-year overall survival of our BC pts was not negatively impacted by the CoV pandemic. Our results show that during the CoV pandemic, BC pts were receiving chemotherapy and hormonal treatment sooner than in the pre-pandemic time, likely due to effective teamwork while implementing national guidelines for triaging and administering neoadjuvant treatment during the pandemic. In contrast to N3C data, CoV pandemic did not negatively impact outcomes or 1-year overall survival in our patients. Future studies will determine if these findings remain at the 5 and 10-year follow-up period.
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Introduction: The COVID-19 outbreak led to the suspension of the Dutch breast cancer screening program, increased the reluctance of patients to visit the general practitioner (GP), and led to a lack of capacity at the GP. As a consequence, the incidence of breast cancer diagnoses decreased. Objective: This study aimed to investigate the impact of the COVID-19 outbreak on the incidence of different stages of breast cancer, by screening status. Methods: Women diagnosed between January 1st 2017 and February 28th 2021 with primary breast cancer without a history of breast cancer were selected from the Netherlands Cancer Registry. March 1st 2020 till February 28th 2021 was regarded as the COVID-19 period. Breast cancer incidence within this COVID-19 period was calculated by tumor stage and compared with the incidence in 2017/2019 (reference). Incidence was expressed per 100, 000 women aged 18 year or older, living in the Netherlands at the start of the year. Thereafter, the COVID-19 period was divided into four subperiods, based on COVID-19 related events: March-April 2020, May-June 2020, July-August 2020, September 2020-February 2021. Incidence in each of those periods was calculated by tumor stage and compared with the incidence in 2017/2019. Analyses were further stratified by screening status. Incidence of screenS detected tumors was expressed per 100, 000 women aged 50-74 living in the Netherlands at the start of the year. Results: A total of 15, 916 women were diagnosed in 2017, 15, 574 in 2018, 15, 867 in 2019, 13, 497 in 2020 and 2, 532 up to February 2021. Compared to 2017/2019, the incidence of DCIS and stage I-III tumors was statistically significantly lower during the COVID-19 period (32%, 24%, 9% and 11% respectively) (Table 1), leading to 603, 1539, 520 and 160 missed diagnoses respectively. The incidence of stage IV tumors was 5% higher, however this was not significant. The incidence of DCIS remained significantly lower throughout the four subperiods, while the incidence of stage I-II tumors was comparable with 2017/2019 in September 2020-February 2021 and the incidence of stage III was comparable with 2017/2019 in both July-August 2020 and September 2020-February 2021. The incidence of DCIS and stage I-II non-screen-detected tumors was significantly lower during March-April 2020 and was comparable with 2017/2019 in the subperiods thereafter. The incidence of DCIS and stage I-IV screen-detected tumors was significantly lower during March 2020-February 2021, with the incidence of DCIS and stage I-III tumors being lower during each subperiod and the incidence of stage IV tumors being lower during May-June 2020. Conclusion: The COVID-19 outbreak led to a decrease in the incidence of DCIS and stage I-III tumor diagnoses, which still lags behind in February 2021. Until February 2021 no stage shift was seen.
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Introduction: The COVID-19 outbreak forced health care services to switch focus to COVID-19 patients, thereby generating pressure on all other health care services, most likely impacting breast cancer care as well. However, the impact of the COVID-19 outbreak on the breast cancer treatment strategy is unknown. Objective: To investigate the impact of the COVID-19 outbreak on the breast cancer treatment strategy. Methods: We selected women diagnosed with breast cancer between January 1st 2018 and June 30th 2020 from the Netherlands Cancer Registry. Women with previous breast cancer or with a synchronous tumor were excluded. The following periods based on COVID-19 related events were analyzed: 2018/2019 (reference), weeks 1-8, weeks 9-12, weeks 13-17, and weeks 18-26 in 2020. Patients were divided into periods based on their date of diagnosis. For patients with DCIS we used logistic regression to investigate the association between period of diagnosis and chance of being treated within six months following diagnosis. For patients with invasive tumors receiving surgery, we used logistic regression to investigate the association between period of diagnosis and chance of receiving a certain type of treatment, adjusting for tumor stage. Furthermore, time length between the following time points were calculated per tumor stage: S 1) diagnosis and first treatment (of any kind), 2) diagnosis and start of neo-adjuvant treatment, 3) diagnosis and operation (no neo-adjuvant treatment was given), 4) end of neo-adjuvant treatment and operation, 5) operation and start of adjuvant systemic treatment, and 6) operation and start of radiotherapy. Time lengths were calculated for each period of 2020 and compared with 2018/2019. Results: A total of 1, 795 DCIS and 11, 785 invasive tumors were diagnosed in 2018, 1, 826 DCIS and 11, 987 invasive tumors in 2019 and 597 DCIS and 4, 566 invasive tumors up to June 2020. Compared to 2018/2019, patients diagnosed with a DCIS were less likely to be treated within six months following diagnosis (ORwks1-8: 0.63, ORwks9-12: 0.50, ORwks18-26: 0.51) (Table). Patients diagnosed with an invasive tumor in weeks 9-12 2020 were less likely to receive neo-adjuvant chemotherapy (ORwks9-12: 0.63), while patients diagnosed thereafter were more likely to receive neo-adjuvant chemotherapy (ORwks13-17: 1.39, ORwks18-26: 1.41). Patients were more likely to receive neo-adjuvant endocrine therapy (ORwks1-8: 1.64, ORwks9-12: 3.14, ORwks13-17: 1.85, ORwks18-26: 1.28), mastectomy (ORwks18-26: 1.32), or adjuvant chemotherapy (ORwks9-12: 1.36), while they were less likely to receive radiotherapy (ORwks18-26: 0.74). Patients receiving a mastectomy for their invasive tumor were more likely to receive an immediate reconstruction (ORwks18-26: 1.57). Compared to 2018/2019, time between diagnosis and first treatment, diagnosis and operation, diagnosis and neo-adjuvant treatment, and operation and adjuvant systemic treatment decreased significantly for patients diagnosed with a stage I-III tumor in weeks 9-12, 13-17 or 18-26. Conclusion: The COVID-19 outbreak affected multiple aspects of the breast cancer treatment strategy and led to a shorter time to therapy, probably due to prioritizing of oncological care and a reduction in the number of patients.
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Background-Physical distancing for COVID-19 led to decreased in-person patient follow up assessments and delayed imaging appointments. Herein we describe for the first time the impact of delays in diagnostic investigations of patients with an history of early-stage breast cancer (BC) in the largest public cancer center of Lombardy, the Italian region most affected by the pandemic. Methods-This single-institution retrospective study included three observational periods. The first pandemic peak period (March-April 2020) corresponding to the interruption of follow up imaging;the post-peak period (May-December 2020);the pre-pandemic period represented by the five previous years (January 2015-December 2019) as control. The flow of diagnostic activities was compared among the different years. Moreover, the number and characteristics of recurrent BC cases (rBC) diagnosed in the post-peak period were compared to the figures observed in pre-pandemic years, when imaging was regularly carried out, using descriptive statistics. A further comparison was performed between the characteristics of scheduled and delayed rBC diagnosed after the first peak. Results-During the first pandemic peak, diagnostic investigations declined by 81.2% (from 1032 in January-February to 194 in March-April), a drop which was not identified in the same period of the pre-pandemic years, before rebounding to 1065 in May-June, 832 July-August (reflecting the Ssummer physiological drop), 1334 September-October, and 879 November-December. The average number of rBC cases of 16 (range 12-25) in March-April of the pre-pandemic period declined to a value as low as 4 during the first pandemic peak. Thereafter, the number of rBC cases began a steady increase, until reaching a total of 27 in September-October 2020, almost doubling the mean of 14.8 (range 11-21) achieved in the corresponding months of 2015-2019. As a result, the absolute number of rBC cases was 76 in 2020 and on average 78.4 (range 70-95) in pre-pandemic years, and the rBC proportion of 1.42% (76/5336;95% exact confidence interval, CI: 1.12-1.78%) in 2020 was slightly higher than the average proportion of 1.26% of the five previous years, though the latter being well included in the CI of the 2020 proportion. No difference in primary tumor presentation and age at initial diagnosis was found among recurrent patients before and after the pandemic. Of the rBC cases reported during 2020, 10 were from 513 patients with postponed follow up who were finally diagnosed between September-December. As compared to patients on schedule, delayed rBC cases did not present with ductal carcinoma in situ, and reported a median tumor size of 18 mm (range 4.3-90 mm), which was 20% higher than the median of 15 mm (3.1-34) observed for scheduled patients. Distribution of luminal-like, triple negative and HER2-overexpressing BC subtypes among evaluable rBC cases was 75%, 12.5%, 12.5% in scheduled and 66%, 11% and 22% in delayed cases, respectively. Conclusions-Our data showed a slight decrease in the absolute number of rBC during 2020 despite a rebound of examinations, and an increased size of invasive recurrence following the 2-month stop of the first pandemic peak. The full impact of the COVID-19 pandemic on recurrent cancer diagnosis will be known when national population-based data become available in the coming years.
ABSTRACT
Background: Neoadjuvant endocrine therapy (NET) has long been limited to patients who were deemed medically unfit for immediate surgery or on clinical trials. Coronavirus disease 2019 (COVID-19) resulted in a global pandemic, which led to deferral of elective surgeries including breast surgeries for early stage breast cancer patients during March-June 2020. Institutional guidelines were developed based on societal recommendations, including NCCN, to use NET as a bridge to surgery. Objective: Primary objective was to establish a database of early stage HR+ Her2/neu-breast cancer patients diagnosed during COVID-19 who were treated with NET as a bridge to surgery. Secondary endpoints include correlation between duration of NET and changes in pathological variables. Method: This was a single institution, retrospective observational study from Perlmutter Cancer Center at NYU Langone Hospital and NYU Langone Hospital-Long Island of DCIS and early stage breast cancer patients diagnosed from March 15, 2020-June 1, 2020 during COVID-19 pandemic. Inclusion criteria were males and females older than 18 years of age and initial diagnosis of DCIS or early stage HR+ Her2/neu-breast cancer who did not require neoadjuvant chemotherapy by established guidelines. Descriptive statistics were calculated separately by DCIS and invasive breast cancer using SAS version 9.4. Results: From March 15-S June 1, 2020, 13 patients who were diagnosed with DCIS and 41 patients with early stage HR+ Her2/neu-invasive breast cancer received NET (Table 1). Of the 41 patients with invasive breast cancer, 19 (46%) had Oncotype DX assay on biopsy specimens;12/19 (63%) had scores 10-14 and 7/19 (37%) had scores 15-25. 38/41 (92.7%) had post-surgery Ki-67% and 16/38 (42.1%) demonstrated maturation arrest (Ki-67 <2.7%). 26/41 (63%) invasive breast cancer patients had pre and post Ki-67% checked while on aromatase inhibitors (AI);21/26 (81%) had a decrease in Ki-67%, 2/26 (7.7%) patients had no change, and 3/26 (11.5%) had an increase. Of those 21 patients, the percent change of Ki-67% from baseline was mean 69.15% ± 22.58 and median 71.83%. No significant associations with changes (pre to post) in Ki-67%, T stage, ER% and PR% in NET for ≤4 weeks and >4 weeks (Table 2). Median duration of NET in invasive breast cancer was 6.85 weeks. 1 patient had a complete pathological response after NET and 2 patients were upstaged from DCIS to invasive carcinoma at the time of surgery. Conclusion: While the sample sizes are small, this is a unique cohort of early stage surgically resectable breast cancer patients who were treated with NET during the COVID-19 pandemic. This real-world data confirms pathological changes, especially decrease in Ki-67% even with short duration use of NET that has been reported in trials of neoadjuvant AI. Long term follow-up for survival outcome is planned.
ABSTRACT
Background: The COVID-19 pandemic strained healthcare systems worldwide, delaying breast cancer screening and surgery. In 2019, approximately 80% of breast cancers in the U.S. were diagnosed on screening examinations, with 76.4% of eligible Medicare patients undergoing screening at least every two years. Since the start of the pandemic, many women have been reluctant to seek elective screening mammography, even with the lifting of "lock-down". We describe the effect of the COVID-19 pandemic on breast cancer presentation at an academic medical center in a city hit hard by the pandemic. Materials and Methods: The institutional IRB-approved Breast Cancer Registry Database was queried for patients enrolled during two time periods, those undergoing first surgical procedure before the start of the pandemic (4/1/2019-3/31/2020) to those the year after the pandemic started (4/1/2020-3/31/2021). Elective cancer surgery was paused for 3 weeks, ending 4/20/2020, and access to routine breast care was limited for 3 months. Variables included age, method of detection, palpability, histologic subtype and staging, neoadjuvant systemic therapy, cancer specific treatments, and radiation uptake. Results: 349 patients were in the 2019 cohort;246 in the 2020 cohort. No differences in baseline characteristics, including age at presentation, nodal status, or operation type. Fewer cancers were detected on routine mammography post-COVID vs. pre-COVID. Increase in detection of breast cancer through self-Sexams in 2020 was seen compared to 2019. Palpability on presentation also increased. More patients were treated with neo-adjuvant therapy chemotherapy, and 36 of 45 (80%) eligible early-stage breast cancer patients accepted neoadjuvant hormonal therapy during the period that elective cancer surgery was on hold. Patients received radiation therapy less frequently during the pandemic. The proportion of patients diagnosed with invasive ductal cancers was higher in the 2020 cohort and the proportion of patients diagnosed with ductal carcinoma in situ (DCIS) and for invasive lobular cancers (ILC) was lower. Conclusions: Patients at an academic New York City medical center presented with more palpable and invasive breast cancers during the COVID-19 pandemic compared to the preceding year, and fewer patients with DCIS and ILC, cancers typically detected following screening mammography. While stage migration with an increase in diagnosis of late stage cancers has been described, in our population the stage shift occurred in early stage breast cancer, with decreases in DCIS and increases in Stages I-II, with the higher stages III-IV essentially unchanged. This reflects the effect of delay in our previously highly-screened population, with an average screening delay of 3 + months, and many patients missing their yearly screening altogether. While many medical interactions during COVID-19 were via telemedicine, radiation therapy requires daily office visits, and fear of exposure contributed to the lower rate of radiation. Given the increase in invasiveness and stage of breast cancers diagnosed during the COVID-19 pandemic, this study emphasizes the importance of screening for diagnosis and treatment of breast cancer, even in the face of a concurrent health crisis.
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Background: The Covid Pandemic has influenced how cancer surgeries are performed and their pre-operative management to allow appropriate social distancing and self-isolation prior to Surgery. With the requirement of wire localisation of non-palpable breast cancers/ lesions on the day of surgery and non-availability of mammogram and ultrasound machine in an isolated zone, we embarked on localisation of non-palpable breast lesions using MagseedR markers and SentimagR localisation system. We describe our initial experience in the management of these cancers and diagnostic excision biopsies using Magseed. Materials and Methods: Forty consecutive female patients, median age 61 (range 36-84) years underwent Magseed insertion for diagnostic excision biopsy (n=4) and breast conservation surgery (WLE;n= 36). Check mammograms were performed following Magseed insertion to confirm appropriate localisation. During the initial audit of 16 patients, one Magseed guided WLE and sentinel node biopsy was abandoned due to erratic signal strength on the day of surgery and underwent surgery with wire localisation on a later date. Subsequently all cases had Magseed signals confirmed following insertion in the radiology department along with check mammograms. Results: Thirty-nine patients underwent successful breast surgery (Magseed in intra-operative specimen X-ray) with standard axillary procedures (29 sentinel node biopsy, 2 axillary node clearance). The median time from magseed insertion to surgery was 13 (range 3-38) days. The lesions were invasive neoplasm +/- insitu (DCIS) disease (n= 32), DCIS (n=5), and papilloma (n=3). The median overall tumour size was 20 (range 3-38) mm and on postop histology was 17 (2-50) mm. Six patients required further re-excision for margin positivity with DCIS;margins were clear after single cavity shave(n=4) and two patients underwent mastectomy subsequently. Conclusions: Magseed localisation have given us significant flexibility in the management of non-palpable breast cancer and indeterminate lesions requiring diagnostic biopsy during the Covid pandemic. Initial audit suggests usefulness of confirming adequate Magseed signal in the radiology department along with check mammogram during the early learning curve.